Podcast Summary:

AACE Podcasts, Episode 71 – 2025 Algorithm for the Evaluation and Treatment of Adults with Obesity/Adiposity-Based Chronic Disease Overview
Release Date: November 5, 2025
Guests: Dr. Carl Nadolski (Chair, Algorithm Writing Group), Dr. Timothy Garvey (Vice Chair)
Host: Dr. David Lee

Episode Overview

This episode presents an in-depth discussion of the newly released 2025 AACE algorithm for evaluating and managing adults with obesity—now reframed as adiposity-based chronic disease (ABCD). The conversation, led by Dr. David Lee with Drs. Carl Nadolski and Timothy Garvey, reviews key scientific advances since the previous 2016 guideline. The hosts critically address shifts in terminology, clinical care models, pharmacological advances, bias reduction, and the practical application of new recommendations for healthcare professionals managing obesity.

Key Discussion Points & Insights

1. Importance of Updating the Algorithm (03:18–04:37)

• Why now?
  The 2016 algorithm was groundbreaking in its "complication-centric" approach and rejection of a BMI-only model. Since then, significant advances in both pharmacotherapies and global perspectives on obesity necessitated an updated framework.
• Expansion of Scope:
  The new algorithm emphasizes the overall chronic disease process of excess adiposity, not just excess body weight.

"We had great advancements in our medical therapy…It really was necessary to make this update because of our new advanced therapies and I think more global attention talking about obesity and adiposity-based chronic disease." — Dr. Carl Nadolski (04:17)

2. Major Changes: From Weight Loss to Complication-Centric Care (04:48–06:23)

• Hierarchies of Preferred Medicines:
  Not just targeting weight loss, but prioritizing therapies based on effective treatment or prevention of specific obesity-related complications.
• Evolution in Trial Design:
  Clinical trials now often have primary endpoints focused on complications (e.g., sleep apnea, MASH, and cardiovascular protection) rather than weight loss alone.
• Personalized Medicine:
  Clinicians can now choose treatments according to the patient’s unique clinical presentation, thanks to direct evidence for medication effectiveness in specific complications.

"We're not just out there to get patients to lose X amount of pounds, but to lose sufficient weight to treat and prevent the complications of the disease." — Dr. Timothy Garvey (04:53)

• Notable Advancements:
  Drugs like semaglutide and tirzepatide show clinical improvements in MASH (metabolic dysfunction-associated steatohepatitis), diabetes, and cardiovascular events.

3. Practical Application: Individualizing Therapy (06:23–09:18)

• Personalized Pharmacotherapy:
  The algorithm provides a framework (notably Figure 8) for selecting medications based on comorbidities such as prediabetes, type 2 diabetes, MASH, or sleep apnea.
  • For example, tirzepatide and semaglutide are preferred for diabetes and MASH due to direct benefits.
  • Bariatric surgery maintains importance, especially for severe cases or where medications are insufficient.
• Dynamic Recommendations:
  The field is evolving rapidly, and updates will continue as more data become available.
• Weighing Efficacy:
  • Expected weight loss responses are classified as incomplete (<5%), good (10–15%), and optimal (>15%), with therapeutic adjustments as necessary.

"We talk about incomplete response where people are only achieving, you know, 5% weight loss or less, 10 through 15% being a good response and over 15% because we know that that's achieving things like remitting sleep apnea, reducing cardiovascular risk, putting type 2 diabetes into remission..." — Dr. Carl Nadolski (09:18)

4. The Evolving Role of Surgery (10:02–11:22)

• Efficacy of Bariatric Surgery:
  Remains a critical tool, especially for those with severe disease/complications. Its impact on mortality and cardiovascular events remains unmatched.
• Medicine and Surgery Balance:
  New medications close the gap in weight loss outcomes, but surgery remains necessary for certain populations and in cases where medication response is inadequate.

"The cardiovascular and life longevity effects of bariatric surgery, that's what always impresses me... these are candidates for bariatric surgery. I mean they can be transformational." — Dr. Timothy Garvey (10:34)

5. Addressing Weight Bias and Stigma (11:22–15:04)

• Internalized and External Bias:
  The algorithm now places significant importance on reducing weight bias, both from healthcare systems and within patients themselves.
• Operational Strategies:
  • Use of validated tools such as the Weight Bias Internalization Scale and Weight Self Stigma Questionnaire.
  • Patient-centered communication (“ask permission to discuss weight,” motivational interviewing, and “the five A’s”).
  • Educating patients that obesity is a biologically driven chronic disease—not a personal failure.

"Just making sure they know it's not their fault, that this is a biologically driven process... we're here to help them and we want to talk about ways we can help them." — Dr. Timothy Garvey (12:42)

"When we acknowledge it and teach them about it and then treat them, they often come back and say, wow, I didn't realize it, it wasn't my fault and now I'm doing well or whatever it is." — Dr. Carl Nadolski (14:43)

6. Reframing the Disease: Adiposity-Based Chronic Disease (ABCD) (15:38–18:21)

• Precision Terminology:
  Moving away from a BMI-centric, weight-focused approach to a health- and risk-focused model.
• Biological and Health Centric Understanding:
  Emphasizes the metabolic and disease process over simple numbers or appearance.

“If we take the opportunity to discuss the true disease process and maybe use the term adiposity-based chronic disease as a bigger umbrella term... it’s truly the overall what’s on the inside that counts.” — Dr. Carl Nadolski (16:18)

"Adiposity based chronic disease is just more medically meaningful and actionable." — Dr. Timothy Garvey (17:08)

7. Practical Takeaways for Clinicians (18:21–23:12)

• Comprehensive Evaluation:
  • Screen for ABCD using waist circumference, waist-to-height ratio (>0.5 is high risk), body composition, and most importantly, presence of complications.
• Risk Staging:
  Not all excess adiposity is equal—complications and severity should drive intensity of therapy.
• Lifestyle Foundation:
  Nutrition, exercise, behavioral therapy, and sleep remain the core of all interventions, regardless of weight loss achieved.

"It's not just bmi. We want to examine them, use waist circumference, waist to height measurements…staging the severity of disease based upon the presence of obesity-related diseases and complication." — Dr. Carl Nadolski (19:05)

8. Nuances of Diagnosis: Preclinical vs. Clinical Obesity (20:32–25:12)

• Debate & Consensus:
  Discussion of the Lancet Commission's framework (preclinical—no complications, vs. clinical—with complications), and AACE’s position that all excess adiposity entails risk.
• Algorithm Staging:
  Stage 1 is not benign—untreated, risk of progression is high, and all sequelae (metabolic, biomechanical, cancer risk) are under consideration.

"Stage one in our algorithm is not a benign state, it just isn't as advanced of a disease state." — Dr. Carl Nadolski (24:41)

9. The Future of Obesity Care (25:12–27:36)

• Wave of Innovation:
  Emerging therapies include GLP-1 analogs, triple agonists, oral drugs, antagonist therapies, and extended dosing regimens. Anticipate more options and greater affordability.
• Tolerability vs. Efficacy:
  Next frontiers: minimizing side effects, maximizing adherence, and tailoring the degree of weight loss to the health needs of each patient.
  • Many patients benefit from 10–15% weight loss; not all need higher reductions.

"I think the field of battle is no longer efficacy, it's tolerability. I mean, why should our patients have to be sick to their stomach for the privilege of having their disease treated?" — Dr. Timothy Garvey (26:23)

Notable Quotes & Timestamps

| Timestamp | Speaker | Quote | |-----------|---------|-------| | 04:53 | Dr. Garvey | “We're not just out there to get patients to lose X amount of pounds, but to lose sufficient weight to treat and prevent the complications of the disease.” | | 09:18 | Dr. Nadolski | “We talk about incomplete response…10 through 15% being a good response and over 15% because we know that that's achieving things like remitting sleep apnea, reducing cardiovascular risk, putting type 2 diabetes into remission...” | | 10:34 | Dr. Garvey | “The cardiovascular and life longevity effects of bariatric surgery, that's what always impresses me... these are candidates for bariatric surgery. I mean they can be transformational.” | | 12:42 | Dr. Garvey | “Just making sure they know it's not their fault, that this is a biologically driven process... we're here to help them…” | | 16:18 | Dr. Nadolski | “If we take the opportunity to discuss the true disease process and maybe use the term adiposity-based chronic disease as a bigger umbrella term... it’s truly the overall what’s on the inside that counts.” | | 17:08 | Dr. Garvey | “Adiposity based chronic disease is just more medically meaningful and actionable.” | | 19:05 | Dr. Nadolski | "It's not just bmi. We want to examine them, use waist circumference, waist to height measurements… staging the severity of disease based upon the presence of obesity-related diseases and complication." | | 26:23 | Dr. Garvey | “I think the field of battle is no longer efficacy, it's tolerability. I mean, why should our patients have to be sick to their stomach for the privilege of having their disease treated?” |

Timestamps for Important Segments

• Background & Speaker Introductions: 00:27–03:18
• Rationale & Major Algorithm Changes: 03:18–06:23
• Medication Selection & Individualization: 06:23–09:18
• Bariatric Surgery Discussion: 10:02–11:22
• Bias/Stigma in Care: 11:22–15:04
• Disease Definition & Approach: 15:38–18:21
• Algorithm’s Key Clinical Takeaways: 18:21–23:12
• Diagnosis Staging & Controversies: 20:32–25:12
• Future Directions in Obesity Care: 25:12–27:36

Summary of Take-Home Messages

• Complication-centric, personalized care has replaced the former BMI-centric model.
• Selection of treatment should be based on type and severity of complications, not weight alone.
• Clinicians should address both external and internalized weight bias, using motivational interviewing and validated screening tools.
• Terminology matters: ‘adiposity-based chronic disease’ is more actionable and patient-centered than ‘obesity’.
• Lifestyle interventions are the foundation, but pharmacotherapy and surgery are critical tools—chosen based on patient needs and risk stage.
• The next frontier is improving tolerability, accessibility, and affordability of therapies, while tailoring interventions to individual patient needs.

For clinicians and care teams, the 2025 AACE algorithm signals a shift: focus on comprehensive, individualized, and health-driven management of obesity/ABCD, integrating emerging therapeutics with robust lifestyle change and social support to maximize both clinical outcomes and patient well-being.